Heart attack risk increased among people with HIV and hepatitis C as they aged

Research Highlights:

  • The risk of heart attack was about 30% higher with each decade of age as people living with HIV got older. However, this risk has increased by 85% every decade in people who also have untreated hepatitis C, according to a new analysis of more than 23,000 people receiving HIV treatment in North America.
  • These results indicate that HIV and hepatitis C status, as well as more traditional risk factors for heart disease, should be considered to reduce heart attack risk.

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DALLAS, Sept. 21, 2022 — As people living with HIV get older, their risk of heart attack increases far more if they also have untreated hepatitis C virus, even if their HIV is treated, according to new research published today in Journal of the American Heart Associationan open access, peer-reviewed journal of the American Heart Association.

Since the introduction of antiretroviral therapies to treat HIV in the late 1990s, life expectancy for people living with HIV has increased dramatically. However, studies have found that the risk of heart disease in people with HIV is at least 50% higher than in people without HIV, even with treatment. This new study looked at whether people with HIV who also have hepatitis C — a viral infection of the liver — were at a higher risk of having a heart attack.

“HIV and hepatitis C co-infections occur because they share the same transmission route — both viruses can be transmitted through blood-to-blood contact,” said Keri N. Althoff, Ph.D., MPH, senior author of the study and Associate Professor in the Department of Epidemiology at the Johns Hopkins Bloomberg School of Public Health in Baltimore. “Due in part to inflammation from the chronic immune activation of two viral infections, we hypothesized that people living with HIV and hepatitis C would have a higher risk of heart attack with age than people living with HIV alone.”

Researchers analyzed health information from 23,361 people living with HIV (17% females, 49% non-Hispanic whites) in the North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD) between 2000 and 2017 who had started antiretroviral treatment for HIV . All were between the ages of 40 and 79 when they enrolled in the NA-ACCORD study (median age, 45 years). One in five study participants (4,677) was also positive for hepatitis C. During a median follow-up of about 4 years, the researchers compared the occurrence of a heart attack between the HIV-only and the HIV-hepatitis C co-infected groups overall and after each decade of age.

The analysis revealed:

  • With every decade of age, heart attacks increased by 30% in people living with HIV alone and by 85% in those who were also positive for hepatitis C.
  • The risk of heart attack increased in participants who also had traditional risk factors for heart disease, such as high blood pressure (more than threefold), smoking (90%) and type 2 diabetes (46%).
  • The risk of heart attack was also higher (40%) in participants with certain HIV-related factors, such as low levels of CD4 immune cells (200 cells/mm3indicating greater immune dysfunction) and 45% in those taking protease inhibitors (a type of antiretroviral therapy associated with metabolic diseases).

“People living with HIV or hepatitis C should ask their doctor about treatment options for the viruses and other ways to reduce their risk of cardiovascular disease,” said study lead author Raynell Lang, MD, M.Sc. , an assistant professor in the Department of Medicine and Community Health Sciences at the University of Calgary in Alberta, Canada.

“Several mechanisms may be involved in the increased risk of heart attack in co-infected patients. A contributing factor may be the inflammation associated with two chronic viral infections,” Lang said. “There may also be differences in cardiovascular disease risk factors and non-medical factors affecting the health of people living with HIV and hepatitis C that play a role in the increased risk.”

According to a June 2019 American Heart Association scientific statement, Characteristics, Prevention, and Management of Cardiovascular Disease in People Living With HIV, approximately 75% of people living with HIV are over the age of 45 and immune system dysregulation appears to be present increase risk of heart attack, stroke and heart failure.” The statement called for more research into the prevention, causes and treatment of cardiovascular disease in people living with HIV.

“Our results suggest that HIV and hepatitis C co-infections require further research that could inform future treatment guidelines and standards of care,” Althoff said.

The study is limited by the lack of information on additional factors associated with heart attack risk, such as diet, exercise, or a family history of chronic health conditions. The results of this study of people living with HIV treated in North America may not be generalizable to people living with HIV in other countries. In addition, the study period predated the availability of more advanced hepatitis C treatments.

“Since no effective and well-tolerated hepatitis C therapy was available during several years of our study period, we were unable to assess the association of treated hepatitis C infection with cardiovascular risk in people living with HIV. This will be an important question that needs to be answered in future studies,” Lang said.

Co-authors are Elizabeth Humes, MPH; Brenna Hogan, MPH; Jennifer Lee, Ph.D.; Ralph D’Agostino, Ph.D.; Joseph Massaro, Ph.D.; Arthur Kim, MD; James B Meigs, MD, MPH; Leila Borowsky, MPH; Wei He, MS; Asya Lyass, MA, Ph.D.; David Cheng, Ph.D.; H. Nina Kim, MD, MSc; Marina B. Klein, MD, MSc; Edward R. Cachay, MD, MAS; Ronald J. Bosch, Ph.D.; M. John Gil, MB, Ch.B.; Michael J. Silverberg, Ph.D., MPH; Jennifer E. Thorne, MD, Ph.D.; Kathleen McGinnis, Dr. PH, MS; Michael A Horberg, MD, MAS; Timothy R Sterling, MD; and Virginia A. Triant, MD, MPH

This analytical study was supported by the National Institutes on Aging and numerous other branches of the National Institutes of Health that support the NA-ACCORD study.

Studies published in the American Heart Association’s scientific journals are peer-reviewed. The statements and conclusions contained in each manuscript are solely those of the study authors and do not necessarily reflect the policy or position of the Association. The Association makes no representations or warranties as to their accuracy or reliability. The association is mainly financed by individuals; Foundations and corporations (including pharmaceutical companies, device manufacturers, and other corporations) also make donations and sponsor specific programs and events of the association. The Association has strict policies to prevent these relationships from influencing scholarly content. Revenues from pharmaceutical and biotech companies, device manufacturers and health insurers, as well as the association’s full financial information, are available here.

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